special psychiatric emergency presentations nicholas cascone, pa-c

Special Psychiatric Special Psychiatric Emergency PresentationsEmergency Presentations

Nicholas Cascone, PA-CNicholas Cascone, PA-C

Emergencies related to Emergencies related to psych medicationspsych medications

Antipsychotics side effectsAntipsychotics side effects Akathisia responds to Akathisia responds to ββ-blocker therapy such as -blocker therapy such as

propranololpropranolol Dystonia (torticollis, oculogyric crises, etc.) respond to Dystonia (torticollis, oculogyric crises, etc.) respond to

anticholinergics (e.g. benztropine, diphenhydramine)anticholinergics (e.g. benztropine, diphenhydramine) Parkinsonism requires dose reduction and Parkinsonism requires dose reduction and

anticholinergic therapy as aboveanticholinergic therapy as above Neuroleptic malignant syndrome: emergency Neuroleptic malignant syndrome: emergency

presentation with rigidity, fever, tachycardia, BP presentation with rigidity, fever, tachycardia, BP lability, and altered mental status – discontinue lability, and altered mental status – discontinue antipsychotic and give dantrolene or bromocriptine, antipsychotic and give dantrolene or bromocriptine, hydration, supportive treatment in intensive care hydration, supportive treatment in intensive care settingsetting

Emergencies related to Emergencies related to psych medicationspsych medications

BenzodiazepinesBenzodiazepines Used frequently in the ED for anxiolysis or sedationUsed frequently in the ED for anxiolysis or sedation

Anxiolytics: alprazolam (XanaxAnxiolytics: alprazolam (Xanax®®), lorazepam (Ativan), lorazepam (Ativan®®), ), clonazepam (Klonopinclonazepam (Klonopin®®))

Longer-acting anxiolytics/mild sedatives: diazepam Longer-acting anxiolytics/mild sedatives: diazepam (Valium(Valium®®), chlordiazepoxide (Librium), chlordiazepoxide (Librium®®))

Sedative-hypnotics: temazepam (RestorilSedative-hypnotics: temazepam (Restoril®®), triazolam ), triazolam (Halcion(Halcion®®), flurazepam (Dalmane), flurazepam (Dalmane®®))

Overdose is treated with flumazenilOverdose is treated with flumazenil Paradoxical response requires discontinuationParadoxical response requires discontinuation

Anorexia nervosaAnorexia nervosa

Dx by usual signs and symptomsDx by usual signs and symptoms BMI 16, < 85% of expected weight for heightBMI 16, < 85% of expected weight for height Unexplained primary amenorrheaUnexplained primary amenorrhea Derangement of body imageDerangement of body image

ED treatment: ED treatment: Volume repletionVolume repletion Correction of electrolytesCorrection of electrolytes Aggressive refeeding leads to hypertonic Aggressive refeeding leads to hypertonic

dehydration, hypernatremia, pancreatitisdehydration, hypernatremia, pancreatitis

Anorexia nervosaAnorexia nervosa

Criteria for hospitalization:Criteria for hospitalization: Weight loss of 30% or more in 3 monthsWeight loss of 30% or more in 3 months Severe metabolic disturbanceSevere metabolic disturbance SuicidalitySuicidality Failure to maintain outpatient weight contractFailure to maintain outpatient weight contract Family crisis or denialFamily crisis or denial Severe bingeing and purgingSevere bingeing and purging Need to initiate therapy (psychotherapy, Need to initiate therapy (psychotherapy,

family therapy, pharmacotherapy)family therapy, pharmacotherapy)

Panic attackPanic attack

SymptomsSymptoms Palpitations/tachycardiaPalpitations/tachycardia Chest pain/pressureChest pain/pressure SOB/smotheringSOB/smothering DiaphoresisDiaphoresis TremorTremor Choking sensation/globusChoking sensation/globus Nausea/abdominal complaintsNausea/abdominal complaints Dizziness/lightheadedness/syncopeDizziness/lightheadedness/syncope ParesthesiaParesthesia Chills/hot flashesChills/hot flashes Fear of: going crazy, loss of control, dying, syncopeFear of: going crazy, loss of control, dying, syncope Derealization/depersonalizationDerealization/depersonalization

Panic attack – medical differentialPanic attack – medical differential

Cardiovascular: angina, MI, MVP, PACsCardiovascular: angina, MI, MVP, PACs Pulmonary: angina, PE, hyperventilationPulmonary: angina, PE, hyperventilation Endocrine: hyperthyroid, hypoglycemia, Endocrine: hyperthyroid, hypoglycemia,

pheochromocytoma, Cushing’spheochromocytoma, Cushing’s Neurological: stroke/TIA, partial seizure, Neurological: stroke/TIA, partial seizure,

migraine, Mmigraine, Mééninièère’sre’s Drugs/medications: caffeine, cocaine, thyroid Drugs/medications: caffeine, cocaine, thyroid

meds, SSRIs, cannabis, steroids, meds, SSRIs, cannabis, steroids, ββ-agonists, -agonists, triptans, nicotine, hallucinogens, anticholinergicstriptans, nicotine, hallucinogens, anticholinergics

Withdrawal syndromes: alcohol, barbiturates, Withdrawal syndromes: alcohol, barbiturates, benzodiazepines, opiatesbenzodiazepines, opiates

Panic attack – treatmentPanic attack – treatment

In ED: benzodiazepinesIn ED: benzodiazepines ReferralsReferrals

Psychotherapy – cognitive-behavioralPsychotherapy – cognitive-behavioral Psychiatry Psychiatry

SSRISSRI BuspironeBuspirone Short-term “bridging” benzodiazepinesShort-term “bridging” benzodiazepines

Emergencies involving alcoholEmergencies involving alcohol

Trauma – assault, MVA, other injuriesTrauma – assault, MVA, other injuries 25% of assaults involve alcohol25% of assaults involve alcohol 45% of fatal MVAs involve alcohol45% of fatal MVAs involve alcohol Head trauma often overlooked when Head trauma often overlooked when

presenting with alcohol intoxicationpresenting with alcohol intoxication Obtain CT of head when:Obtain CT of head when:

History of head injuryHistory of head injury No improvement in 3 hoursNo improvement in 3 hours Worsening of mental status while under observationWorsening of mental status while under observation


WithdrawalWithdrawal Four steps of alcohol withdrawalFour steps of alcohol withdrawal

6 – 8 hours since last drink: autonomic 6 – 8 hours since last drink: autonomic hyperactivity – tachycardia, diaphoresis, tremorhyperactivity – tachycardia, diaphoresis, tremor

24 hours since last drink: tactile and visual 24 hours since last drink: tactile and visual hallucinationshallucinations

24 – 48 hours since last drink: motor seizures24 – 48 hours since last drink: motor seizures 3 – 5 days since last drink: delerium tremens – 3 – 5 days since last drink: delerium tremens –

altered mental status, convulsive seizures, 5 – altered mental status, convulsive seizures, 5 – 15% mortality15% mortality


Treatment of alcohol withdrawalTreatment of alcohol withdrawal Fluid resuscitation with D5NS or D5LR and thiamine Fluid resuscitation with D5NS or D5LR and thiamine

(100 mg/L)(100 mg/L) Patient placed in a quiet area with minimal stimulationPatient placed in a quiet area with minimal stimulation Lorazepam 2 – 4 mg IV q 15-30 minutes until light Lorazepam 2 – 4 mg IV q 15-30 minutes until light

sedation is achievedsedation is achieved MgSOMgSO44: 4 g IV in 1 – 2 hours: 4 g IV in 1 – 2 hours

For pts with seizures:For pts with seizures: CT indicated if head trauma, focal seizure, persistent post-CT indicated if head trauma, focal seizure, persistent post-

ictal defect in consciousnessictal defect in consciousness


Criteria for admissionCriteria for admission Medical complications such as CHF, infectionMedical complications such as CHF, infection More than 8 mg of lorazepam neededMore than 8 mg of lorazepam needed

Referral for treatment of alcoholismReferral for treatment of alcoholism

Tests for conversion disorder/ Tests for conversion disorder/ malingeringmalingering

SensationSensation Yes/no test: pt closes eyes and responds yes/no to Yes/no test: pt closes eyes and responds yes/no to

touch stimulus – “no” response favors conversiontouch stimulus – “no” response favors conversion Bowlus & Currier test: Bowlus & Currier test:

pt extends crossed arms, thumbs down, palms touching, pt extends crossed arms, thumbs down, palms touching, interlocking fingers, arms then rotated towards chestinterlocking fingers, arms then rotated towards chest

False response to sensory stimulus difficult d/t distortion of False response to sensory stimulus difficult d/t distortion of positionposition

““Strength” test: pt closes eyes and moves touched Strength” test: pt closes eyes and moves touched finger to assess “strength”. True sensory loss would finger to assess “strength”. True sensory loss would not allow pt to determine which finger is being testednot allow pt to determine which finger is being tested


PainPain Gray test of abdominal painGray test of abdominal pain

With psychological pain, pt closes eyes during palpationWith psychological pain, pt closes eyes during palpation With organic pain, pt watches palpation so they can guard tender With organic pain, pt watches palpation so they can guard tender

areasareas MotorMotor

Drop test: “paralyzed” extremity dropped from above the face will Drop test: “paralyzed” extremity dropped from above the face will miss itmiss it

Thigh adductor test: examiner places hands against inner thighs Thigh adductor test: examiner places hands against inner thighs of patient. Pt is told to adduct normal leg against resistance. In of patient. Pt is told to adduct normal leg against resistance. In pseudoparalysis, other leg will also adductpseudoparalysis, other leg will also adduct

Hoover test: examiner cups both heels of patient. Pt is told to Hoover test: examiner cups both heels of patient. Pt is told to elevate normal leg. In pseudoparalysis, other leg will push elevate normal leg. In pseudoparalysis, other leg will push downward. Pt is told to elevate weak leg. Absence of downward. Pt is told to elevate weak leg. Absence of downward pressure indicates noncompliance.downward pressure indicates noncompliance.


ComaComa Corneal reflexes retained in awake patientCorneal reflexes retained in awake patient

SeizureSeizure Resistance to covering of mouth & nose indicates Resistance to covering of mouth & nose indicates

pseudoseizurepseudoseizure Palpation of abdominal muscles reveals lack of Palpation of abdominal muscles reveals lack of

contraction in pseudoseizurecontraction in pseudoseizure BlindnessBlindness

Opticokinesis: tape with alternating black and white Opticokinesis: tape with alternating black and white sections pulled laterally in front of patient’s open eyes sections pulled laterally in front of patient’s open eyes induces nystagmus in patient with intact visioninduces nystagmus in patient with intact vision

special psychiatric emergency presentations nicholas cascone, pa-c

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